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Trish- it is unfortunate that so often we cannot recommend over-the-counter analgesics such as Tylenol and ibuprofen to our patients. Our patients frequently have to avoid these medications to avoid masking a fever, or for liver or renal concerns. I feel like it is often narcotics or nothing, which isn’t fair to them. Of rouse the article also mentions narcotics don’t help, so I feel like we don’t have many answers for them. If this side effect really is as common as 70%, I’m surprised there isn’t more data available.
Jeff- I didn’t think of other long-acting antihistamines. For some reason we always suggest Claritin. You would think that others would work as well. I’ve also never asked patients if the bone pain is worse where they have old injuries or arthritis.
Reena- I would think that our pre-infusion Benadryl would have worn off by the time the post-infusion Neulasta causes bone pain. But it would be worth finding out if Benadryl taken after Neulasta helps with bone pain.
Hi, I am Jennifer Clark, I work in the CTU.
1. What was the knowledge gained from the article?
I was interested in reading the theories laid out in the Lambertini et al article of the etiology of the bone pain post pegfilgrastim treatment; expansion of the marrow, acceleration of the inflammatory process, nerve stimulation and increased osteoblast/osteoclast production. It makes sense that a patient would experience bone pain during therapy. I also find it very interesting that it seems like the recommendation of using Claritin has come from anecdotal posts on online blogs and forums and not really from EBP and literature review.2. Will the research/information in this article change or influence your practice? If so how?
I knew that bone pain was a possibility but I was unaware of the incidence of it in patients. In the different studies cited, it ranges from 20% to 71%. One of our previous Multiple Myeloma physicians always recommended the use of Claritin but I never knew the reasoning behind it. Some CTU patients have their treatment held for low counts and they are prescribed a round of Neupogen so I will definitely tell them to try Claritin (after checking with their provider, of course).3. What other questions does the article raise about current practice?
I feel more studies need done in this area due to the incidence of patient’s experiencing PIBP. I feel that they are educated that it may happen so they feel like they need to just deal with it because it is expected. Both articles mention that both acetaminophen and NSAIDs are effective as well, but both are discouraged in the oncology population due to the adverse effects of both. Other histamine blockers that are better tolerated should also be studied so patient’s have better options.4. Do you agree/disagree with the conclusions of the author, why?
I do agree that more studies need done with larger sample sizes, different combinations of drugs, etc. to find better treatments for PIBP. We have limited information on something so prevalent.Thanks for hosting Trish! These articles were very informative. I was not aware that Loratidine was recommended for 7 days after pegfilgrastim dosing. I will definitely tell my patients that are having several doses of Neupogen to montior for bone pain and try it.
Michelle, I wonder why brand name Claritin is more effective than generic. Also, it seems like many clinics already recommend the use of it for PIBP. I feel like that information does not trickle down to infusion areas so we can educate our patients better.
Mindy, I thought about the high dose vitamin c as well when reading these articles. I think it sadly stems back to the fact that companies cannot make money off of vitamin c therapies and won’t suggest it even though the semi limited research was very positive in managing side effects.
Trish- I have heard that narcotics do not touch the pain patients still report having the bone pain from OBI.
Hello my name is Patti and I currently work at SSBC infusion. My breast cancer patients often receive pegfilgrastim with their chemotherapy regimens.
What was the knowledge gained from the article?
The articles provided a great review on the drug mechanism. I didn’t realize that bone pain was as prevalent as 45%. I wasn’t aware of providers suggesting famotidine as a treatment option. The breast cancer providers often recommend claritin.Will the research/information in this article change or influence your practice? If so how? I will continue to encourage the patient to use antihistamines. I will let patients know that they can use both claritin and famotidine so that bot histamine 1 and 2 receptors are blocked.
What other questions does the article raise about current practice?
I think another journal participant brought this up but What non-pharmacological methods could be used for pain management?
The SSCBC infusion patients received reiki during their infusion prior to COVID. I witnessed the benefit this had on many patients and their pain, fatigue, and anxiety.Trish, I appreciate you organizing this post and picking this topic. I am new to oncology and can learn a lot from a triage nurse! I guess the reason you are only permitted to advise patients to take loratadine for bone pain is because Acetaminophen has hepatic toxicity side effects, plus the fact that it can mask neutropenic fevers. The article also tells us that NSAIDS are contraindicated due to thrombocytopenia, GI side effects, and renal dysfunction. Breast cancer patients often take all three medications to treat bone pain, so continued studies on the effectiveness, dosage, frequency and duration of these prophylactic treatments is important.
Reena and Michelle,
I enjoyed reading both of your responses about these articles. That was a great thought/question Reena had about whether or not benadryl helps with pegfilgrastim-induced bone pain. Michelle learned that benadryl is for acute reactions and has a shorter duration, but loratadine lasts longer which it makes it better to treat the bone pain. Benadryl has much worse side effects in my opinion. Many of our patients get benadryl before chemo to prevent reactions, but it makes them tired and dizzy, plus they get restless legs, which is extremely uncomfortable. Loratadine is definitely the best bet, and if that works without other medication to relieve the bone pain, that is ideal for our patients.Moore, D. C., & Pellegrino, A. E. (2017) mention that a dose reduction of pegfilgrastim can be an option to reducing the adverse side effect of bone pain. It was discussed that the risk of Febrile Neutropenia was higher for those who received the lower dose of pegfilgrastim.
Does neupogen the short acting growth factor have a lower incidence of bone pain? You may adjust dose easier with the short acting drug.I know that tylenol and ibuprofen have a risk of masking a fever but directing the patient to take their temperature prior to taking these antipyretics would help decrease that risk.
Michelle-Thank you for the information about benadryl….I wondered if the mechanism of action was different and that is why it is not a preferred intervention.
Mindy-I too wonder if vitamin C would have any effect on the alleviation of bone pain.
I wonder why more research has not been completed in this area of treatment because bone pain is not something that has been a new symptom of treatment.
Hi All! My name is Holly and I work in OP JCRU. Thanks Trish for the articles! Good topic!
1. Knowledge gained? LOTS!!!
I was unaware that there were four separate theories about PIBP-expansion of bone marrow, inflammation/histamine release, afferent nerve stimulation, and osteoclast/osteoblast mediated bone resorption. They all make sense.
I was also unaware that taxane based chemotherapies could potentially cause increased pain if G-CFS received after. I wonder why?
I didn’t realize the reducing the dosage of G-CFS was an option and could potentially reduce or eliminate pain.
Finally, I also didn’t know famotidine along with loratidine was potentially more effective than loratidine alone.
2. How will this influence practice? I will definitely have patients talk to their providers about different options as to how to control this pain. I feel like it’s always just been loratidine for a few days before and a week after.
3. Other questions raised? LOTS!!!
We don’t usually recommend nsaids or acetominophen due to masking fever, but if they are effective, shouldn’t that be an option?
Why haven’t celebrex, gabapentin, pregabalin been studied for their effectiveness for this?Since this is such a prevalent issue with our patients receiving G-CFS, sounds like a lot more attention to doing research studies needs to occur.
Hey Patti, I didn’t realize the incidence of bone pain was that high either. Makes me feel like I should be really digging in and asking my patients how they are doing with their OBIs. Perfect time to remember would be when we are putting them on.
Reena, I would almost hate it if they studied the benadryl just because of all of the side effects. While PO form is not near as bad as IV, the side effects are too numerous. I would be afraid people would have a higher incidence of falls. With that being said, it does make you wonder. What about zyrtec or allegra?
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